1. Presented by:
Dr. Mohd Anuar Bin Awang
Dr. Ainin Tasneem Bt Abdul Rafa
Supervised by:
Dr. Norhafiza Bt Ab Rahman
1st
July 2014

2. CONTENT
• Introduction
• Fluid compartments & distribution
• Principle of fluid therapy
• Common electrolytes imbalance, causes &
management
• Take home messages
• References

3. INTRODUCTION
• Water & electrolyte balance is crucial for body
hemostasis & is one of the most protected
physiological mechanism in body
• A critical role of kidney is to maintain circulating
volume, plasma osmolality & electrolyte hemostasis
within relatively narrow limit
• Changes in both fluid volume & electrolyte
composition occur preoperatively, intraoperatively
& postoperatively, as well response to trauma or
sepsis

4. MOHD ANUAR
FLUID

5. TOTAL BODY WATER
• Varies with age, gender and body habitus

6. FLUID COMPARTMENTS

7. Total body water (TBW)
(70kg man )
42L
ECF
1/3 of TBW
14 L
ICF
2/3 of TBW
28L
Interstitial fluid
¾ of ECF
11 L
Plasma
¼ of ECF
3L
TBW =0.6X Body Weight

8. BODY FLUID COMPOSITION

9. FLUID EXCHANGE

10. Volume Composition
Disturbance in Fluid
Balance
Hypovolumia
Hypervolumia
Sodium
Potassium
Calcium
Magnesium
Phosphate

11. FLUID THERAPY

12. PRINCIPLE OF FLUID THERAPY
1. Correction of existing fluid abnormalities
• Fluid resuscitation
• Sepsis (sepsis bundle) – 30 ml/kg
• Burn = TBSA(%) x 4 x body weight (kg) – Parkland’s formula
2. Maintenance of daily requirement
• Normal ongoing loss – Sensible & insensible
3. Replacement of ongoing abnormal losses
4. Reassess the patient ( clinical and laboratory
parameter eg. blood pressure, urine output, central
venous pressure )

13. FLUID MAINTENANCE
100/50/10 rule
•100ml/kg for first 10kg
•50ml/kg for next 10kg
•20ml/kg for every kg (divided
by 24 for hourly rate)
4/2/1 rule
• 4 ml/kg/H for the first 10kg
• 2 ml/kg/H for next 10kg
• 1 ml/kg/H every kg
(total is according to/H)
Average: 30-40 ml/kg/day

14. CASE ILLUSTRATION
• Mr X is a 50 year old man with weight of 70 kg. He
has no known comorbids. He was electively
admitted for inguinal repair for reducible right
inguinal hernia. He was planned to be kept NBM by
12 midnight.

15. 1) HOW TO CALCULATE FOR FLUID MAINTENANCE
FOR HIM?
Using 100/50/20 formula:
•100 x 10kg =1000 ml
•50 x 10 kg = 500 ml
•20 x 50 kg = 1000 ml
Total = 2500 ml
Using 4/2/1 formula:
•4 x 10kg =40 ml/H
•2 x 10 kg = 20 ml/H
•1 x 50 kg = 50 ml/H
Total 110 ml/H x 24 H = 2640 ml
Using average 35 ml/kg/day: 2450 ml
≈ 5 pints

16. What type of fluid to give?
To be continued……………….

17. ROUTE OF ADMINISTRATION
• Enteral
• Parenteral
• Crystalloids
• Colloids
• Blood products

18. CRYSTALLOID COLLOID
DEFINITION Balanced salt solution,
administered intravenously
Plasma expander containing
larger insoluble molecules
ADVANTAGES • Cheaper
• Easily available
• More shelf life
• Not disturb coagulation
• Less risk of APO
• Ratio of replacement 1:1
DISADVANTAGES • Ratio replacement 1:3
• More risk of APO
• Expensive
• Disturb coagulopathy

19. CRYSTALLOID
1) Hypotonic
• HS , 1/5 NSD5,
2) Isotonic
• NS, HM, D5%
3)Hypertonic
• D10%, mannitol, 3% NS, NSD5

20. SODIUM CHLORIDE 0.9%
(NORMAL SALINE)
• Isotonic solution (150mmol
Na + 150 mmol Cl per litre)
• Useful for resuscitation
• Potential risk of
hyperchloraemic metabolic
acidosis & hypernatraemia
where large volume are
administered

21. HARTMANN’S SOLUTION
• Contains Na, K, Ca, Cl &
lactate
• Most physiological
especially when large
volume are required
• Useful in resuscitation of
burn patient
• However contains
excessive Na, lower level
of Cl & can cause
metabolic acidosis if
being use as the sole fluid

22. DEXTROSE 5%
• Isotonic solution - No
electrolytes
• 50 g/L of glucose
• Provide modest calories
(1L - 200kcal)
• Rapidly metabolized &
distribute evenly
throughout the all
compartments

23. COLLOID
• Gelatin based
• E.g Gelafundin
• Starch based
• E.g. Voluven

24. AININ TASNEEM
ELECTROLYTES

25. SODIUM

26. SODIUM
• Normal requirements: 1 - 2
mmol/kg/day
• Normal level: 135 – 145 mmol/L
• The major cation of the ECF &
therefore the osmotic pressure is
governed by sodium concentration

27. HYPONATREMIA
• Vomiting, diarrhea,
• burn
• bowel obstruction
• third space loss
• diuretics
• dilutional
related to brain cell
swelling
•Mild
Asymptomatic
•Moderate Restlessness,
confusion,altered mental
state
•Severe Seizure,coma
CAUSES
CLINICAL
FEATURES

28. • Rapid correction of Na may cause
central pontine myelinolysis; < 10
mmol/24H for chronic
• Correct Na fast (3mmol/L for first 3 hour)
for acute
• Modality of treatment
3% NaCl = 513 mmol/L
0.9 % NaCl = 154 mmol/L
• Change in Se Na=‘
Infusate Na – Serum Na
(TBW+1)
• Bolus of 100 ml of 3% hypertonic saline
which generally raise serum sodium level
by 2-3 mmol/L
MANAGEMENT OF
HYPONATREMIA

29. HYPERNATREMIA
CAUSES
Inadequate water
intake, Vomiting,
diarhea, Excessive
sweating, diuretics,
salt ingestion,
CLINICAL FEATURES
related with cerebral
dehydration; Tremor ,
irritability, dizziness,
weakness , mental
confusion, coma
MANAGEMENT
Target fall in serum Na
concentration of 10
mmol/L/day
Modality of treatment:
D5% = 0 mmol/L of
sodium
0.45 % NaCl =77
mmol/L of sodium

30. POTASSIUM

31. POTASSIUM
• Requirements : 0.5 – 1 mmol/kg/day
• Normal level : 3.5 – 5 mmol/L
• Potassium is the main cation within the
cell
• Its high concentration in cell is being
maintained by the Na-K ATPase pump

32. HYPOKALEMIA
• vomiting,
• diarhea
• Ileostomy
• Sweating
• Burn
• insulin treatment
• beta agonist
• Alkalosis
• leucocytosis
K < 2.5 mmol/L
Neuromuscular
- weakness
- cramps,
- paraesthesia
- paralysis
Gastrointestinal
- Constipation
- ileus
CVS
– Arrythmias; AF, VT, VF, Heart
block
CAUSES
CLINICAL
FEATURES

33. Oral therapy (K > 2.5 mmol/L):
- Mist KCl 15 ml TDS
- T. Slow K (1 tablet = 600mg = 8 mmol/L)
IV therapy (K < 2.5 mmol/L), ECG changes,
symptomatic, unable to take orally:
IV KCl, rate: <20 mmol/hr
Fast correction
1g KCL in 100cc NS over 1 H
1 g K = 13.3 mmol
K deficit:
(Desired value – Patient’s value) x body wt (in kg) x 0.4
13.3
K maintainance:
Body weight (in kg)
13.3
Done under cardiac monitoring
MANAGEMENT
OF
HYPOKALEMIA

34. HYPERKALEMIA
• Acidosis
• insulin
deficiency
• Intravascular
haemolysis
• tumour lysis
syndrome
• crush injury
Usually occur when K > 6.5
mmol/L
Neuromuscular: Weakness,
paraesthesia, areflexia,
ascending paralysis
Cardiac: Bradycardia,
prolongation of AV
conduction, complete heart
block, wide complex
tachycardia, ventricular
fibrillation, assystole
CAUSES
CLINICAL
FEATURES

35. Severe lytic coctail
-10 mls 10% IV calcium
gluconate
- 50 mls IVD50% (30 – 60mins)
- 10U rapid acting insulin
-Then, maintain with D5%
IV salbutamol 0.5 mg
Sodium Bicarbonate infusion
Dialysis
MANAGEMENT
OF
HYPERKALEMIA

36. CASE ILLUSTRATION
• Remember Mr X? Overnight, he started to
complaint of pain over affected site with persistent
vomiting. His blood investigations were repeated &
he was reassessed again.

37. 2) He was put on NBM. What fluid regime to start?
• Fluid maintenance =
(100 x 10) + (50 x 10) + (20 x 50) = 2500 ml
• Na maintenance = 1-2 mmol/kg = 70-140 mmol/day
• K maintenance = 0.5-1 mmol/kg = 35-70 mmol/day
• Therefore =
• 2 pints NS (0.9% NaCl) = 150 mmol Na + 1 L water
• 3 pints D5% = 1.5 L water + 150 g glucose
• 70 mmol KCl = 5.26 g

38. 3) After persistent vomiting, he was noted to be confused. His Na
level came back as 111 mmol/L. How to correct his Na level?
• Total body water = 70 x 0.6 = 42 L
• He is severely symptomatic  Correct Na fast
• Correct 3 mmol/L in 3 hour with 3% NaCl
• Change in serum Na = Infusate Na – Serum Na
Total body water + 1
= 513 – 111
42 + 1
= 9.35 mmol/L
• To aim for 3 mmol/L elevation = 3 ÷ 9.35
= 0.32 L of 3% NaCl
= 320 ml 3% NaCl over 3 hour

39. 4) His K level came back as 3.0 mmol/L. How to
correct his K level?
•K deficit =
(4.0 – 3.0) X 70 X 0.4
13.3
= 2.1 g
•Solution = Fast correction 2 g KCl in 200 ml NS over 2
hours

40. CALCIUM

41. CALCIUM
• Requirements : 0.1 mmol/kg/day
• Normal level: 8.5 – 10.6 mg/dL; 2.1-2.65 mmol/L
• Functions:
• Bone density
• Muscle contraction
• Second messenger for hormones & neurotransmitters
• Blood coagulation pathway (intrinsic pathway)

42. HYPOCALCEMIA
• Hypoparathyroidism
• post thyroidectomy
• vitamin D deficiency
• severe sepsis
• Burn
• phosphate therapy
• Paraesthesia
• circumoral numbness
• cramp
• Tetany
• Dystonia
• Convulsion
• psychosis
SIGN
• Chvostek’s sign
• Trousseau’s sign
• Dry skin(long standing)
CAUSES
CLINICAL
FEATURES

43. Acute:
•10-20ml of IV Ca gluconate
10% dilute in 100 ml NS over 10
min
•±IVI at 0.5-2mg/kg/hour (10-
50ml of Cal gluconate in 500ml
D5% over 4-8 hours)
Long term:
•1-2 elemental Cal (Cal
lactate/Ca carbonate) TDS
•Calcitriol 0.25mcg daily
MANAGEMENT OF
HYPOCALCEMIA

44. HYPERCALCEMIA
CAUSES
Hyperparathyroidism, .
Humoral hypercalcemia
of malignancy (Breast
ca, SCC, RCC, ovarian
ca),
CLINICAL FEATURES
“Stones, bones,
abdominal moans,
psychic groans”
MANAGEMENT
Rehydration & saline
diuresis
0.45-0.9% saline, about
(3-4 L) for 2-3 days
IV frusemide
Biphosphonates -
Pamidronate 30 mg stat
dose
Dialysis

45. • Water constitute 50-60% of body weight
• The principal extracellular cation is Na and principal
anion are Cl and HCO3.
• In contrast principal intracellular cation is K and Mg
and principal anion is PO4
• In normal individual, fluid balance is achieved
through water intake and loss.
• Water loss can be divided to insensible and sensible
loss
• Extracellular volume deficit is most common fluid
disorder in surgical patient
TAKE HOME MESSAGES

46. • Most acute surgical illness are accompanied by
some degree volume loss or redistribution, thus
isotonic fluid administration is most common initial IV
fluid given.
• The most important type of hyponatraemia in
surgical patients is due to hypovolumia thus
management is directed towards replacement of
water volume & Na level.
• Symptoms of hypernatraemia are related to
hyperosmolarity effect of Na which results in cellular
dehydration
• Hypokalaemia is one of the important cause of ileus

47. REFERENCES
• Schwartz’s Principle of Surgery (9th
edition), G. Tom
Shires 111, 2010
• The Washington Manual of Surgery (6th
edition),
Klingensmith et al, 2012
• Maintainance and replacement fluid therapy in
adult, H Stern, Uptodate.com, 2014
• Sarawak Handbook of Medical Emergencies, 3rd
edition, Soo et al, 2011
• Surgicall Recall, 6th
edition, Blackbourne, 2012